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2019年03月09日 临床话题, 模拟诊室 暂无评论


Early Administration of Antibiotics for Suspected Sepsis

Michael Y. Mi, Michael Klompas, Laura Evans

N Engl J Med 2019; 380:593-596
DOI: 10.1056/NEJMclde1809210

Case Vigenette 病例

A Man with Hypoxemia and a Woman with Acute Kidney Injury


Michael Y. Mi, M.D.

Mr. Shui is a 35-year-old man who is brought to the emergency department by ambulance after falling from the crest of a tall wave while surfing. He had been in the water for approximately 10 minutes before a lifeguard reached him and brought him to shore. At that time, he was unconscious and coughing and had a palpable pulse. A friend accompanied him to the nearest community hospital, where you work. The friend thinks that Mr. Shui is generally in good health and takes no medications regularly, but earlier in the day, Mr. Shui mentioned to his friend that he had felt slightly fatigued and had had a persistent cough for 2 days. He drinks alcohol occasionally. He does not smoke tobacco but smokes marijuana regularly.


On examination, his temperature is 36.0°C, blood pressure 98/65 mm Hg, heart rate 110 beats per minute, respiratory rate 24 breaths per minute, and oxygen saturation 90% while he is breathing ambient air. He opens his eyes and moves his limbs in response to commands but is confused and disoriented. Breath sounds are diminished at the base of both lungs. There is a 3-cm laceration on the right side of his scalp. The remainder of the physical examination is unremarkable. The complete blood count is notable for a white-cell count of 12,400 per cubic millimeter. Electrolyte levels, renal function, and liver-function tests are within normal limits. Arterial blood gas analysis reveals a pH of 7.37, partial pressure of oxygen (Po2) of 60 mm Hg, partial pressure of carbon dioxide (Pco2) of 36 mm Hg, and lactate level of 2.2 mmol per liter. A chest radiograph shows bibasilar air-space opacities. Computed tomography (CT) of the head and neck without administration of contrast material shows no acute intracranial abnormalities and no fractures of the cervical spine.

体格检查发现,体温36.0°C,血压98/65 mm Hg,心率110 bpm,呼吸频率24 bpm,吸空气时氧饱和度90%。患者可遵嘱睁眼及活动肢体,但意识模糊,定向力障碍。双肺底呼吸音减低。右侧头皮有3-cm裂伤。其余体格检查没有异常发现。血常规检查白细胞计数12,400/mL。电解质、肾功能及肝功能检查均正常。动脉血气分析pH 7.37,Po2 60 mm Hg,Pco2 36 mm Hg,乳酸水平2.2 mmol/L。胸片显示双侧肺底实变。头颅及颈部CT平扫未发现急性颅内异常,颈椎未见骨折。

Ms. Wilkinson is a 72-year-old woman with a history of hypertension and urgency urinary incontinence who presents to the emergency department with a 1-day history of acute-onset abdominal pain in the left lower quadrant. Before the onset of abdominal pain, she had had constipation for 3 days and had not urinated for 1 day despite her efforts to drink plenty of water. She takes extended-release oxybutynin, at a dose of 30 mg daily, and she was recently given a prescription for hydrochlorothiazide, 25 mg daily. She does not smoke or drink alcohol.

Wilkinson女士是一名72岁女性患者,有高血压及尿潴留病史。患者因急性起病的左下腹疼痛1天到急诊就诊。在腹痛发生前,患者便秘3天,尽管大量饮水,但一整天未排尿。患者服用缓释奥西布宁30 mg qd,近期开始服用双氢克尿塞25 mg qd。患者不吸烟也不饮酒。

Her temperature is 36.7°C, blood pressure 126/75 mm Hg, heart rate 100 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 99% while she is breathing ambient air. On examination, she has tenderness to palpation of the left lower quadrant of the abdomen. She is alert and fully oriented. Cardiac and pulmonary examinations are normal. Laboratory studies show a creatinine level of 2.0 mg per deciliter (180 μmol per liter), anion gap 21 mmol per liter, white-cell count 24,200 per cubic millimeter with a predominance of neutrophils, hematocrit 45.0%, and lactate 3.9 mmol per liter. CT of the abdomen and pelvis with administration of contrast material shows large stool volume in the descending and sigmoid colon without evidence of gastrointestinal wall edema or hypoenhancement. A chest radiograph shows clear lungs without focal consolidations. An indwelling urinary catheter is placed, and 1 liter of urine is drained. Results of urinalysis are within normal limits.

患者体温 36.7°C,血压126/75 mm Hg,心率100 bpm,呼吸频率18 bpm,吸空气时氧饱和度99%。体格检查发现,触诊左下腹时有压痛。患者意识清楚,定向力正常。心肺检查正常。实验室检查发现肌酐2.0 mg/dL (180 μmol/L),阴离子间隙21 mmol/L,白细胞计数24,200/mL,中性粒细胞为主,血球压积45.0%,乳酸3.9 mmol/L。腹部及盆腔增强CT显示降结肠及乙状结肠内大量粪便,没有胃肠道水肿或低密度表现。胸片显示肺部正常,未见局灶实变。患者留置尿管,引流尿液1 L。尿常规检查结果正常。

You are the on-call provider caring for both Mr. Shui and Ms. Wilkinson. You suspect that there may be infections underlying the presentations of both patients, but you are not certain. You believe that early administration of antibiotics to patients with sepsis may save lives, but antibiotics can have serious adverse effects. Your task is to decide whether to administer antibiotics in addition to providing supportive care.


  1. Do not administer antibiotics. 不应使用抗生素
  2. Administer antibiotics immediately. 立即使用抗生素

Option 2 选项2

Administer Antibiotics Immediately 立即使用抗生素

Laura Evans, M.D.

Both Mr. Shui and Ms. Wilkinson have presented for medical care with signs and symptoms that arouse concern for sepsis; however other explanations are also possible. Thus, the question in these cases is about the diagnostic certainty required to begin therapy — specifically, the potential risks of withholding therapy as compared with the risk of the therapy itself.


Sepsis is defined by Sepsis-3 as “life-threatening organ dysfunction caused by a dysregulated host response to infection.”1 In patients with sepsis, timely initiation of antimicrobial therapy is a cornerstone of treatment. To break the decision down, there are two steps the clinician must take: decide whether infection is present or suspected and assess whether the patient has acute organ dysfunction attributable to the known or suspected infection. I will address both steps in each case.


Whether infection is present is unclear from the presentation of each patient, although it is reasonable to suspect infection in both patients. Mr. Shui had been fatigued and had had a cough for 2 days before his presentation. He has borderline hypothermia and hypotension, tachycardia, tachypnea, and hypoxemia with a mild elevation of his white-cell count, and he has decreased breath sounds at the lung bases and bibasilar opacities. Aspiration without infection is certainly an alternative explanation in the context of a nonfatal drowning event, but infection cannot be ruled out at this stage. Similarly, Ms. Wilkinson presents with abdominal pain, urinary retention while she is taking an antispasmodic agent, and a markedly elevated white-cell count. Despite the negative urinalysis, infection cannot be fully ruled out at this time.


Regarding step two, the Sepsis-3 definition suggests the use of the SOFA score to assess for organ dysfunction, whereas previous definitions used slightly different criteria.1,10,11Mr. Shui has hypoxemia and altered mental status. Ms. Wilkinson has acute kidney injury and a creatinine level of 2.0 mg per deciliter. Both patients have elevated lactate levels, which is commonly used as a biomarker of end-organ dysfunction in sepsis even though the lactate level is not included in the SOFA score.10,11

至于第二步,sepsis-3定义提示使用SOFA评分评价器官功能障碍,而既往的定义采用不同的诊断标准。Shui先生有低氧血症和意识障碍。Wilkinson女士发生急性肾损伤,肌酐水平2.0 mg/dL。两名患者均有乳酸水平升高,后者常作为脓毒症时终末器官功能障碍的生物标志物,尽管并未包括在SOFA评分中。

The Surviving Sepsis Campaign guidelines strongly recommend initiation of intravenous antimicrobial agents within 1 hour or, if possible, even sooner, both in patients with sepsis and in patients with septic shock.12 Published data corroborate the studies that were used to inform the guideline recommendation, with the data showing a 4-to-7% increase in the odds ratio for death for each hour delay in the initiation of antimicrobial therapy.6,13


Both Mr. Shui and Ms. Wilkinson have possible infection, and both patients have definite signs of acute organ dysfunction. The potential risk of withholding therapy is high in both patients, whereas the risk of prompt and appropriate antibiotic therapy until more information is available is low. I would give both patients an initial dose of antibiotics while continuing to evaluate for infection. That said, a commitment to antimicrobial stewardship is essential. If further investigations are negative for infection, de-escalation or discontinuation of unnecessary antimicrobial agents is critical to reduce the risk of antibiotic-associated adverse drug effects and antimicrobial resistance.14



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